Effects of cognitive behavioral therapy for adults with post-concussion syndrome: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Although the mechanism of post-concussion syndrome remains unclear, psychological factors are thought to be associated with its development. Cognitive behavioral therapy is the gold standard for psychological disorders; however, its effects on post-concussion syndrome remain unclear. Through this meta-analysis, we assessed the effects of cognitive behavioral therapy on post-concussion syndrome following traumatic brain injury.

METHODS

Six electronic databases were searched from inception to September 15, 2019, for randomized controlled trials evaluating the effects of cognitive behavioral therapy for adults with post-concussion syndrome. Primary outcomes included the severity of symptoms of post-concussion syndrome, depression, anxiety, and social integration. Secondary outcomes were fatigue, cognitive function, and quality of life. Effects were estimated through the calculation of Hedge's g and 95% confidence interval using a random effects model. Sensitivity analyses were conducted by excluding studies in which an intention-to-treat analysis was not employed.

RESULTS

In total, 24 studies were included. Most studies had risk of bias. Significant effects were found for most outcomes, except for severity of symptoms of post-concussion syndrome, fatigue, executive function, and problem solving. After sensitivity analyses, the effects of cognitive behavioral therapy remained significant for immediate and mid-term effects on depression, anxiety, and social integration.

CONCLUSIONS

This study does not support the effectiveness of cognitive behavioral therapy for severity of symptoms of post-concussion syndrome; however, it might be an effective treatment option for improving depression, anxiety, and social integration in individuals with traumatic brain injury.

The bidirectional gut-brain-microbiota axis as a potential nexus between traumatic brain injury, inflammation, and disease

As head injuries and their sequelae have become an increasingly salient matter of public health, experts in the field have made great progress elucidating the biological processes occurring within the brain at the moment of injury and throughout the recovery thereafter. Given the extraordinary rate at which our collective knowledge of neurotrauma has grown, new insights may be revealed by examining the existing literature across disciplines with a new perspective. This article will aim to expand the scope of this rapidly evolving field of research beyond the confines of the central nervous system (CNS). Specifically, we will examine the extent to which the bidirectional influence of the gut-brain axis modulates the complex biological processes occurring at the time of traumatic brain injury (TBI) and over the days, months, and years that follow. In addition to local enteric signals originating in the gut, it is well accepted that gastrointestinal (GI) physiology is highly regulated by innervation from the CNS. Conversely, emerging data suggests that the function and health of the CNS is modulated by the interaction between 1) neurotransmitters, immune signaling, hormones, and neuropeptides produced in the gut, 2) the composition of the gut microbiota, and 3) integrity of the intestinal wall serving as a barrier to the external environment. Specific to TBI, existing pre-clinical data indicates that head injuries can cause structural and functional damage to the GI tract, but research directly investigating the neuronal consequences of this intestinal damage is lacking. Despite this void, the proposed mechanisms emanating from a damaged gut are closely implicated in the inflammatory processes known to promote neuropathology in the brain following TBI, which suggests the gut-brain axis may be a therapeutic target to reduce the risk of Chronic Traumatic Encephalopathy and other neurodegenerative diseases following TBI. To better appreciate how various peripheral influences are implicated in the health of the CNS following TBI, this paper will also review the secondary biological injury mechanisms and the dynamic pathophysiological response to neurotrauma. Together, this review article will attempt to connect the dots to reveal novel insights into the bidirectional influence of the gut-brain axis and propose a conceptual model relevant to the recovery from TBI and subsequent risk for future neurological conditions.

Impact of pre-injury family functioning and resources on self-reported post-concussive symptoms and functional outcomes in persons with mild TBI

OBJECTIVE

This study investigates the contribution of pre-injury family functioning and resources on self-reported post-concussive symptoms and functional outcomes in persons with mild TBI (mTBI).

DESIGN

Participants with uncomplicated or complicated mTBIs were recruited from consecutive admissions to the emergency department of a level 1 trauma centre. Patients completed baseline assessments within 2 weeks of injury and an outcomes assessment at 3 months post-injury.

METHODS AND PROCEDURES

One hundred and sixty-six adults with mTBI were included. Baseline measures of pre-injury history, family functioning and resources were obtained. Functional status assessments and self-reported measures of health, common TBI symptoms and psychological problems were administered at 3-months post-injury.

RESULTS

Data reduction of outcome measures using principle components analysis revealed two factors: self-reported post-concussive symptoms and current functional/participation status, explaining 60.53% of the variance. Family resources (β = -0.239, t(150) = -2.84, p = 0.005) and age (β = -0.170, t(150) = -2.19, p = 0.030), but not family functioning, were significant predictors of self-reported post-concussive symptoms at follow-up, R² = 0.051, F(5, 150) = 4.09, p = 0.002. Neither family resources nor functioning predicted current functional/participation status.

CONCLUSIONS

Fewer family resources and younger age were associated with increased self-reported post-concussive symptoms. Fewer resources may be a potential risk factor to heightened perception of post-concussive symptoms. Providing low-cost counselling or resource facilitation services may improve outcomes for those with limited resources after mTBI.

Physiological emotional under-arousal in individuals with mild head injury

PRIMARY OBJECTIVES

This study examined the potential emotional sequelae following self-reported mild head injury (MHI; e.g. 'altered state of consciousness' [ASC]) in university students with a particular focus on arousal status and responsivity to experimental manipulation of arousal.

RESEARCH DESIGN

A quasi-experimental design (n = 91) was used to examine arousal status (self-reported and physiological indices) and response to manipulated arousal (i.e. induced psychosocial stress/activation; reduced activation/relaxation) between persons who acknowledged prior MHI and persons with no-MHI.

MAIN OUTCOME AND RESULTS

University students who self-reported MHI were physiologically under-aroused and less responsive to stressors (both laboratory and environmental) compared to their no-MHI cohort. Those with reported loss of consciousness demonstrated the most attenuated emotional arousal responses (i.e. flattened electrodermal responsivity) relative to those with only a reported ASC, followed by those with no-MHI.

CONCLUSIONS

The under-arousal in traumatic brain injury has been hypothesized to be associated with ventromedial prefrontal cortex disruption. This under-arousal may be mirrored in persons who self-report experiencing subtle head trauma. Students who reported MHI may be less able to physiologically respond and/or cognitively appraise stressful experiences as compared to their no-MHI cohort; and experience subtle persistent consequences despite the subtle nature of the reported head trauma.